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. 1999 Jan 30;318(7179):332. doi: 10.1136/bmj.318.7179.332

Using research findings in clinical practice

Doctors advocating evidence based medicine may be out of touch with real medicine

John Main 1
PMCID: PMC1114797  PMID: 9924076

Editor—Is it possible that the evidence based medicine lobby is so busy reviewing the literature that it has lost touch with the rather disorderly world of real medical practice? Certainly Straus and Sackett provide convincing evidence of that in their article telling us how to use research findings in practice.1 Having decided that the most important of several questions that a casualty officer could ask when faced with an alcoholic, confused man with cirrhosis who is bleeding is “Does treatment with somatostatin reduce the risk of death?”, they conclude that the answer is unknown. The correct course is therefore to form a therapeutic alliance with the patient, discuss the potential risks and benefits, and then reach a decision.

Although confused alcoholic patients in Oxford may be more able to discuss clinical pharmacology than those from Middlesbrough, I doubt that that is the explanation for this strange approach to this medical emergency. I can conclude only that there are no trials in the literature that prove that a discussion of the risks and benefits of somatostatin with a confused man who may be bleeding from oesophageal varices is not only pointless but associated with a poor outcome.

What Straus and Sackett are suggesting may be a useful learning exercise for a junior doctor but is nothing to do with the practice of medicine. The correct response from the casualty officer in this case would be a rapid telephone call to someone who already knows how to deal with such problems without scurrying off to the ward computer.

Until those advocating evidence based medicine have a better understanding of what actually happens when patients and doctors meet, their scrupulous search for the truth will provide a disappointingly small input into the practice of medicine.

References

  • 1.Straus SE, Sackett DL. Getting research findings into practice: Using research findings in clinical practice. BMJ. 1998;317:339–342. doi: 10.1136/bmj.317.7154.339. . (1 August.) [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 1999 Jan 30;318(7179):332.

Authors’ reply

S E Straus 1, D L Sackett 1

Editor—In case other readers made the same mistakes as Main in reading our paper, we would like to re-emphasise four points.

Firstly, practising evidence based medicine begins and ends with clinical expertise. In our clinical service (we admit about 200 patients a month) unstable patients therefore receive immediate care from a team that comprises staff with as many sorts of expertise as required; that’s not what the paper was about.

Secondly, a typical inpatient generates five questions for clinicians who are willing to admit that they don’t have all the answers. We therefore decided that our most useful contribution would be to describe how busy clinicians can pare these down to one answerable question by balancing various factors. These factors might be: which question is most important to the patient’s wellbeing; which is it most feasible to answer in the time available; which is most interesting to the clinician; and which answer is most likely to be applicable in subsequent patients?

Thirdly, as we have published elsewhere, pre-appraised evidence often can be accessed by busy clinicians in seconds.1-1

Finally, we would suggest (as does every professional body we know about) that doctors’ duty includes establishing an alliance (not to describe clinical pharmacology, but to discuss the benefits and risks of treatment) with every patient (or his or her surrogate).

Main’s final sentence is wrong, too. Audits in medicine,1-2 surgery,1-3 psychiatry,1-4 and general practice1-5 have all shown that clinical services that strive to provide evidence based care can do so for about four fifths of their patients.

References

  • 1-1.Sackett DL, Straus SE. Finding and applying evidence during clinical rounds: the “evidence cart.”. JAMA. 1998;280:1336–1338. doi: 10.1001/jama.280.15.1336. [DOI] [PubMed] [Google Scholar]
  • 1-2.Ellis J, Mulligan I, Rowe J, Sackett DL. Inpatient general medicine is evidence based. Lancet. 1995;346:407–410. [PubMed] [Google Scholar]
  • 1-3.Kenny SE, Shankar KR, Rentala R, Lamont GL, Lloyd DA. Evidence-based surgery: interventions in a regional paediatric surgical unit. Arch Dis Child. 1997;76:50–53. doi: 10.1136/adc.76.1.50. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 1-4.Geddes JR, Game D, Jenkins NE, Peterson LA, Pottinger GR, Sackett DL. What proportion of primary psychiatric interventions are based on randomised evidence. Qual Health Care. 1996;5:215–217. doi: 10.1136/qshc.5.4.215. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 1-5.Gill P, Dowell AC, Neal RP, Smith N, Heywood P, Wilson AK. Evidence based general practice: a retrospective study of interventions in our training practice. BMJ. 1996;312:819–821. doi: 10.1136/bmj.312.7034.819. [DOI] [PMC free article] [PubMed] [Google Scholar]

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